Biofilms in dental unit waterlines (DUWLs) are extremely difficult to eliminate. Aim of this study is to evaluate the efficacy of a mixture of four D-amino acids on biofilm dispersion in DUWLs. 600 of the dispersed biofilms. Remnants of biofilms on the DUWLs were evaluated by SEM. In clinic, fifteen DCUs were incubated with test and control solutions, flushed, and measured OD600 of the dispersed biofilms. Microbial count of DUWL output water was enumerated twice a week for four weeks.  A mixture of four D-amino acids , distilled water (control), and 0.1 M hydrochloric acid (HCl) was used in the experiment. In laboratory, pieces of DUWLs covered with biofilms were submerged in different solutions for 5 days, flushed, and measured OD600 of flushing water in D-amino acids group. D-amino acids effectively reduced bacterial plaque as demonstrated by SEM. Incubation with D-amino acids significantly reduced biofilms especially after the first day of flushing. Bacterial count in DUWL output water was significantly reduced after treatment with D-amino acids.  There was a slight, but not significant, increase in OD D-amino acids are applicable as biofilm dispersing agents in DUWLs. Biofilms, the term for a community of microorganisms, are resistant to physical and chemical stresses. Biofilms can be found in any aquatic environment including pipelines of medical devices . In dentNumerous approaches have been introduced to decrease the presence of DUWL biofilms. These include both nonchemical and chemical methods. Regarding a nonchemical strategy, which includes flushing, drying, and applying an antimicrobial filter, using deionized, distilled, or even sterile water appears not to affect existing biofilms , 2. The Amino acids (except glycine) can occur in two isomeric forms; these are called L- and D-forms. Only L-amino acids are produced by cells and incorporated into proteins. Therefore, most natural amino acids are in the L-form. D-amino acids are found in the cell walls of bacteria, but not in their proteins. D-amino acids have been proposed to be stress signaling and are released during depletion of nutrients to trigger the dispersion of “old” biofilms . These DB. subtilis biofilm by affecting the function of amyloid fibers. When noncanonical D-amino acids incorporate into peptidoglycan, they interfere with the anchoring of amyloid fibers that normally assists in holding the biofilms together [B. subtilis cell wall and interferes with transpeptidation and transglycosylation. The disturbance of the composition of the bacterial cell wall specifically interferes with biofilm formation [µM, and of D-Leu was 8.5 mM. D-Tyr proved to be the most effective among the four. Nonetheless, the mixture of all four amino acids is more effective than D-Tyr alone. As for the dispersion of biofilms, D-Tyr (3 µM) or a mixture of D-Tyr, D-Met, D-Tryp, and D-Leu (2.5 nM each) breakdowns the biofilm pellicle of B. subtilis [Staphylococcus aureus and Pseudomonas aeruginosa biofilms [D-amino acids are also involved in inhibition of bacterial biofilm formation and dispersion. Kolodkin-Gal et al. demonstrated that D-amino acids could disperse together . Bucher ormation . D-aminoormation . The minsubtilis . Not onlbiofilms –16.E. faecalis biofilms grown on human dentin slabs [E. faecalis. The inhibitory effect of D-amino acids on biofilm formation was concentration dependent. The authors of this study, therefore, proposed D-amino acids as a novel biofilm inhibitor in endodontic treatment [Recently, several studies have proposed D-amino acids as candidate molecules to be applied as a biofilm dispersing agent in endodontic treatment. Rosen et al. demonstrated that D-Leu was effective in inhibiting in slabs . Zilm etreatment .These effects of D-amino acids on biofilm dispersion together with their safety support their use as a candidate for the removal of biofilms in DUWLs. Therefore, the present study aims to investigate the efficacy of D-amino acid mixtures on the removal of biofilm in DUWLs.DUWLs covered with biofilm, as was judged by eye, were obtained from in-use dental chair units (DCUs) and cut into small pieces with a length of 2.5 cm. A mixture of four D-amino acids, consisting of D-methionine , D-tryptophan , D-leucine , and D-tyrosine , was prepared by dissolving them in 0.1 M hydrochloric acid (HCl) to get a final concentration of 10 mM (each). In a preliminary set of experiments, we assessed that 10 mM was the most effective concentration of D-amino acids to be used for the removal of a biofilm.The DUWLs were submerged in 4 mL of one of the following three solutions: (i) distilled water (negative control), (ii) D-amino acids, and (iii) 0.1 M HCl (dissolvent control). The samples were incubated at room temperature for 5 days before each sample was rinsed 3 times with 1 mL of distilled water. The dispersed biofilm from each sample was collected to sonicate and to measure the OD at 600 nm. The DUWL samples were then fixed with 2.5% glutaraldehyde for 24 hours and washed with 1 mL of PBS for 3 times. They were then dehydrated, critical-point dried, gold-sputter coated, and examined using a scanning electron microscopy  at a magnification of ×2000. Biofilms found inside the reservoir bottle of DCUs were also incubated with test and control solutions for 5 days, flushed, and visualized with SEM.µL of each sample onto R2A agar plates, and these were then incubated at 35°C. The baseline CFUs were assessed after 7 days of incubation. In the D-amino acids and HCl groups, the water supplying the DCUs was replaced with a mixture of D-amino acids or 0.1 M HCl, respectively.Fifteen dental chair units (DCUs) were randomly divided into 3 groups of 5 DCUs each: distilled water (negative control), D-amino acids, and 0.1 M HCl (dissolvent control). The study used DCUs of the dental school during summer break; a period during which the DCUs were not in use. Before the start of the experiment, water from the DUWLs was collected to evaluate the initial bacterial CFUs. The water samples were sonicated for 5 minutes to disperse clumps of microorganisms. Then, a serial ten-fold dilution was performed before plating a 100 In order to limit the amount of D-amino acid used in each DCUs, the minimum amount of water that completely flushed to the outlet of the waterline was determined by flushing diluted gentian violet into the DUWL. Fifty-five mL of the tested solution was determined as an appropriate amount to completely fill up the waterlines with testing solution. The test solutions were left in the tubing of DUWLs for 5 days. After 5 days of incubation, the waterlines were repeatedly flushed with 1.6 liters of water every other day for 10 days and the flushing water was collected to measure the OD at 600 nm. After flushing, 25 mL of water from each unit was collected and sonicated for 5 minutes. The samples were diluted ten-fold, plated on R2A agar, and incubated at 35°C for 7 days. The bacterial CFUs were then counted. Bacterial contamination in DCU output water samples was evaluated twice a week repeatedly for 4 weeks .U test were used for both in vitro and clinical experiments. Significance was set at p values < 0.05.All data were analyzed using SPSS 18. The Kruskal–Wallis test and the Mann–Whitney Biofilm mass was shown to cover the inner surface of DUWLs as shown by SEM . After 5In the clinical setting, the highest OD of dispersed biofilms was observed on the first day of flushing in the group treated with the D-amino acid mixture . After tOur results demonstrated that a mixture of D-amino acids consisting of D-methionine, D-tryptophan, D-leucine, and D-tyrosine at a final concentration of each amino acid of 10 mM was effective in dispersing biofilm in DUWLs. This cleaning effect was found both in an in vitro setting and in a clinical setting. SEM analysis revealed that bacterial biofilms inside the DUWL were eliminated after incubation with the D-amino acid mixture for 5 days. Treatment of the DUWLs with the D-amino acid mixture also significantly reduced bacterial contamination in output water of DCUs. In previous studies, the efficiency of D-amino acids in dispersing biofilms has been demonstrated in vitro with single species biofilms or microbial aggregates formed by mixed cultures , 14, 19.Many methods both mechanical and chemical have been utilized to reduce bacterial contamination in dental unit waterlines, but none of these methods were able to disperse the existing biofilms in the complex tubing system of DUWLs. The efficiency of controlling bacterial contamination in DUWLs depends solely on chemical or physical methods of destroying or removing planktonic bacteria. Thus, the effectiveness of D-amino acid in the removal of existing biofilms in the complex dental unit tubing system appears to be an attractive way to remove biofilms from the inner parts of medical devices.Streptococcus mutans occurs more rapidly as the pH drops [Our findings demonstrate the efficiency of D-amino acids in this process. It should be noted that also treatment of the waterlines with HCl alone partially removed biofilms. This effect might be due to the acidity of hydrochloric acid and its effect on biofilm dispersion , 21. AccStaphylococcus aureus biofilm [µM of D-tyrosine or a mixture of D-Tyr, D-Met, D-Tryp, and D-Leu (2.5 nM each) to disrupt the B. subtilis biofilm [The concentration of D-amino acid mixture used in our study is slightly higher than the one used in previous studies , 14. Yet biofilm . The conB. subtilis biofilms which are known to produce this type of matrix [S. aureus and P. aeruginosa, D-amino acids appear to trigger the disassembly of biofilms. The exact mechanisms involved in how D-amino acids disperse biofilms need further examination [Besides a biofilm-dispersing property, D-amino acids have also been demonstrated to inhibit or slow down the growth of biofilms , 22, 23.f matrix , 13. Howmination , 26.A mixture of D-amino acids was shown to partly remove biofilms in dental unit waterlines. This study, therefore, proposes the use of such a mixture as a new approach to decontaminate bacterial biofilms in dental unit waterlines.


Background. This study compared outcomes of abdominal lifting and compression cardiopulmonary resuscitation (ALP-CPR) with standard CPR (STD-CPR). Materials and Methods. Patients with cardiac arrest seen from April to December 2014 were randomized to receive standard CPR or ALP-CPR performed with a novel abdominal lifting/compression device. The primary outcome was return of spontaneous circulation (ROSC). Results. Patients were randomized to receive ALP-CPR (n = 40) and STD-CPR (n = 43), and the groups had similar baseline characteristics. After CPR, 9 (22.5%) and 7 (16.3%) patients in the ALP-CPR and STD-CPR groups, respectively, obtained ROSC. At 60 minutes after ROSC, 7 (77.8%) and 2 (28.6%) patients, respectively, in the ALP-CPR and STD-CPR groups survived (P = 0.049). Patients in the ALP-CPR group had a significantly higher heart rate and lower mean arterial pressure (MAP) than those in the STD-CPR group . The posttreatment PCO2 was significantly lower in ALP-CPR group than in STD-CPR group . PO2 was significantly increased after ALP-CPR , but it was not changed after STD-CPR. PO2 after CPR was significantly higher in the ALP-CPR group . There were no differences between genders and for patients who are > 65 or ≤ 65 years of age. Conclusions. The abdominal lifting and compression cardiopulmonary resuscitation device used in this study is associated with a higher survival rate after ROSC than standard CPR. Even when immediate cardiopulmonary resuscitation (CPR) is administered after cardiac arrest, the restoration of spontaneous circulation (ROSC) success rate has remained relatively low , 2. As aAbdominal lifting and compression cardiac resuscitation devices can perform active compression and lifting based on the “thoracic pump,”  “abdominThe purpose of this study was to compare the outcomes of an abdominal lifting and compression device with those of conventional CPR in patients with cardiopulmonary arrest.The effectiveness, safety, and stability of the abdominal lifting and compression device used in this study have been verified in animal and human experiments . This stThis was a prospective study conducted at Zhengzhou People's Hospital from April to December 2014. Adults of both genders with a body weight of 40–150 kg meeting American Heart Association (AHA) guidelines for cardiopulmonary arrest seen in the emergency department were eligible for inclusion . The criAbdominal lifting and compression CPR (ALP-CPR) and standard CPR (STD-CPR) were used to treat patients in accordance with a random number table generated using SPSS 20.0 software. Numbers from the random number table were assigned on a unified basis by the hospital's emergency center dispatching department. All patients received orotracheal intubation, respiration with the aid of a rebreathing bag, and electrocardiograph monitoring. Two intravenous lines were established and rapid infusion of 250 mL × 2 of 0.9% sodium chloride solution was given. Defibrillation was administered as needed. All personnel providing care were trained in advanced CPR techniques and the use of the abdominal lifting/compression device.A model CPR-LW1000 abdominal lifting/compression device invented by Professor Wang Lixiang of the General Hospital of Armed Police Forces' Emergency Medical Center and produced by the Beijing Germari Medical Equipment Co., Ltd., was used to perform ALP-CPR . The devIn compliance with AHA guidelines, lifesaving treatment was considered successful and terminated with the appearance of an autonomous aortic pulse, moist facial complexion, the appearance of autonomous respiration, and shrinking pupils and reappearance of a light reflex, or the appearance of eyeball motion and limb spasms . If afteThe primary outcome measure was ROSC rate  ≥ 50–60 mm Hg, maintained for ≥20 minutes). Secondary outcome measures were blood pressure, heart rate, blood gas parameters, and MAP before, during, and after patient resuscitation. Viability at 30 and 60 minutes after ROSC was also recorded.Z-test. Continuous variables were presented by mean and standard deviation, and differences between the two groups were tested with the independent two-sample t-test, and changes from baseline to after CPR within groups were tested with the paired t-test. Sex of the two groups was presented by number and percentage, and differences were tested with Fisher's exact test. Values of P < 0.05 were considered to indicate statistical significance. All analyses were performed using SPSS 22 statistical software .The primary endpoint, ROSC, was presented by number and percentage, and the difference of ROSC rate between the two CPR groups was tested with the two-proportion β) and a significance level of 0.05 (α).According to the equation below, at least 45 subjects were required in each group to detect a difference of ROSC rate between the ALP-CPR and STD-CPR groups with the power of 0.8  (1 − p1 and p2 were set at 0.21 [Equation:  at 0.21  and 0.48 at 0.21 .A flow diagram of patient selection and disposition is shown in Patients in the two groups had comparable baseline characteristics Tables  and 2.P = 0.049)  and 7 (16.3%) patients in the ALP-CPR and STD-CPR groups, respectively, obtained ROSC. At 30 minutes after ROSC, 7 (77.8%) and 4 (57.1%) patients, respectively, in ALP-CPR and STD-CPR groups survived and the difference did not reach statistical significance. At 60 minutes after ROSC, 7 (77.8%) and 2 (28.6%) patients, respectively, in the ALP-CPR and STD-CPR groups survived, and the survival rate was significantly higher in the ALP-CPR group (= 0.049) .P < 0.001; MAP: 60.0 versus 67.3 mmHg, P = 0.003). The respiration rate of the two groups after CPR was not significantly different. At 30 minutes after ROSC, the 7 patients in ALP-CPR group had a significantly higher heart rate than the 4 patients in STD-CPR group , and the pH in the ALP-CPR group was reduced to a greater degree than in the STD-CPR group  (P = 0.005).The blood pH levels of the two groups were comparable at baseline and then decreased after CPR  . The pH 2 showed no significant change after ALP-CPR, but it was significantly increased after STD-CPR . PCO2 was significantly decreased after ALP-CPR , but it was not changed after STD-CPR. The posttreatment PCO2 was significantly lower in the ALP-CPR than in STD-CPR group . PO2 was significantly increased after ALP-CPR  but was not changed after STD-CPR. PO2 after CPR was significantly higher in the ALP-CPR group than in the STD-CPR group .SPO+ and lower Ca2+ level compared to the STD-CPR group at baseline, but compared to baseline levels no significant change of K+ and Ca2+ was observed after CPR. The LAC levels of the two groups were comparable at baseline, and then both decreased after CPR , but the reduction was less in the ALP-CPR than in the STD-CPR group  (The ALP-CPR group had a higher K< 0.001) .P < 0.001)  .+ . For the STD-CPR patients, there were no significant differences of vital signs and changes of blood gas measurements between those who are >65 years and ≤65 years of age, except for Ca2+   .The results of this study showed that while ROSC was comparable between the two groups, survival after ROSC was significantly better in the ALP-CPR than the STD-CPR group (77.8% versus 28.6%). Significant changes in blood gas measurements were observed, and outcomes were not affected by sex or age.After more than 50 years of investigation and practice, although the ROSC rate has increased, the resuscitation success rate of CPR remains inadequate , 2. Ches2. After negative pressure results in abdominal suction, the user operates the instrument in accordance with the display screen and the audio signals. The compression force is 40–50 kg, which is equivalent to pressure of 1.96–2.45 kgf/cm2 on the abdominal wall (1.90–2.37 atmospheres) [Abdominal lifting and compression CPR is a new technology that generates artificial circulation and ventilation via the thoracic, abdominal, and heart pump mechanisms . The insspheres) . In addispheres) .In most cases of primary cardiopulmonary arrest, blood still contains some oxygen during the early period. As a result, the reduction in oxygen to the myocardium and brain is chiefly due to reduced circulation and not to reduced ventilation or a drop in blood oxygen, which is why the restoration of circulation is emphasized during the early stage of resuscitation . HoweverLarge-scale study has reported that compression-only CPR or STD-CPR are equivalent with respect to prognosis and ROSC rate . However+ and Ca2+ levels between the groups, this was not of clinical significance to this study; as for both groups, the K+ and Ca2+ levels were not excessive to have impacted heart resuscitation.While there were some statistically significant differences in baseline KThere are limitations to this study that should be considered. The study was performed at a single center, and the number of patients was limited. Due to the limited sample and the fact that most cases of cardiac arrest occur among older patients, age groups younger than 65 years were not examined. Autopsies were not performed in nonsurvivors and thus we were not able to determine if abdominal lifting and compression resulted in abdominal injuries.The abdominal lifting and compression cardiopulmonary resuscitation device used in this study is associated with a higher survival rate after ROSC than standard CPR. The device is recommended for use in the lifesaving treatment of cardiac arrest patients who have contraindications against standard chest compression. However, we also have some limitations that no autopsy data on abdominal damage are available. There might has been damage with peak pressure of over 760 mmHg.


Fractures of the distal radius are common with a variable prognosis in case of intra articular extension. The available options include Plaster, External fixation, Prefabricated Splintage using Ligamentotaxis, K-wire fixation, and open reduction internal fixation with T-plate without an as yet clear advantage of one over the others. If these fractures are allowed to collapse, radial shortening, angulation and articular incongruity may cause permanent deformity and loss of function. This limited small scale study was intended to compare the functional results of treatment of these fractures with a T plate and K-wires.This was a prospective experimental study conducted at department of Orthopedics of PGMI/Lahore General Hospital, Lahore. Total 30 patients were included and randomized into two groups of 15 patients each. Group-A patients were treated with Krischner’s wires and Group-B patients were treated with a T-Plate with open reduction. Informed consent was taken. Post operative follow up was done for 12 weeks for the outcome parameters (Green and O’Brien score).Mean age of patients in Group-A and B was 36.13±9.81 and 44.73±7.86 years respectively. In Group-A there were 10 male and 5 female patients and in Group-B there were 8 male and seven female patients respectively. In Group-A nine patients presented with Fernandez type-II and six patients presented with Fernandez type-III fracture. While in Group-B 10 patients presented with Fernandez type-II and five patients presented with Fernandez type-III fracture. Among Group-A patient’s final outcome was excellent in 86.67% patients while in Group-B only 53.33% patients had excellent outcome at three months follow up.Percutaneous Kirschner’s wires appeared to be more effective as compared to T-Plate fixation in terms of functional outcome for treating intra-articular distal radius fractures. A locking plate fixation has gained popularity in recent years in management of distal radius fractures. Anatomical restoration of articular surface and fragments alignment promote functional return and avoids early osteoarthritic changes.Thirty patients were included in the study on-probability convenient sampling with random allocation to study Groups A&B as they presented to emergency and OPD. Only patients with distal radial fractures within one week of injury were taken and patients with injuries elsewhere to the same bone fresh or old were avoided. Patients with open fractures were excluded. The sample size was calculated with 95% confidence interval, 10% margin of error, and magnitude of excellent outcome i.e. 63.2% with K-wire use and 66.6% with T-plate. Both groups were counseled as per IRB requirements and an informed consent was taken. All patients were operated by consultant staff using percutaneously K-wires under c-arm guidance and plaster cast in Group A. Group B was operated through volar approach, under tourniquet control and the use of a volar AO plate. Similar plaster splints, antibiotic  and analgesic regimens were used in both groups. Stitches were removed in Group B after 10 days and a gentle physiotherapy plan was instituted. Casts were removed at 3-4 weeks in the other group and wires were extracted after 4-6 weeks. A similar rehabilitation program consisting of assisted and active range of motion exercises was done in both the groups for three months.Functional recovery was measured in terms of Green O’ Brien Scoring system.Mean age of patients in Group-A and Group-B was 36.13±9.81 and 44.73±7.86 years. Minimum age in Group-A and Group-B was 26 and 25 respectively. While maximum age in both treatment groups was 55 years. In Group-A Male: Female ratio was 2:1 & Group-B it was 1:0.87.Most of the patients fell in Fernandez classification II/III . Grip stRozenthal et al. 2009Beharrie et al. in 2004We feel that k-wire group produced better results regarding pain, functional outcome and disability in the end although these were not our measured outcomes. The internal-fixation group had more complications like swelling stiffness of fingers and stitch abscesses. Lesser time for operation and lower cost also favored Percutaneous k-wire stabilization. Our study has a very short follow-up duration and is limited to study of one outcome only. It would be prudent to base ones conclusions upon a meta analysis or a large scale study in this matter.Percutaneous Kirschner’s wires appear more effective as compared to T-Plate fixation in terms of functional outcome for treating intra-articular distal radius fractures.JIK under supervision of OA.The study was conducted in partial fulfillment of MS Orthopedics by JIK and TM collected data while JIK and OA analyzed it.JIK and FNH prepared the manuscript.


Universal adhesives are new systems that can be used in etch-and-rinse (ER) and self-etch (SE) modes. This in vitro study evaluated the bonding performance of a universal adhesive in ER mode and SE mode with two irrigants for luting fiber posts in the root canal.After separation of the roots from the crowns of 56 maxillary central incisors and endodontic treatment, 10-mm post space was prepared. The roots were divided into seven groups according to irrigant/adhesive protocol used for cementation of posts: 1) sodium hypochlorite (NaOCl) irrigant + acid etching + One-Step Plus, 2) NaOCl + Clearfil SE Bond (CSE) and 3) EDTA + CSE as controls; 4) NaOCl + All-Bond Universal (AB) in ER mode, 5) NaOCl + AB in SE mode, 6) EDTA + AB in SE mode, 7) distilled water + AB in SE mode. Posts were luted using Duo-link. The bonded roots were sectioned into microslices. After push-out bond strength (PBS) testing, data in MPa were analyzed with two-way ANOVA and Tukey test (α = 0.05).PBS was significantly affected by irrigation/adhesive protocol and root region (P<0.05), with no significant interaction of these factors. PBS of ABU in ER mode with NaOCl and in SE mode with NaOCl or EDTA was comparable to that in the respective controls. The highest and lowest PBSs were recorded for ABU in the SE mode with EDTA (15.38 ± 4) and NaOCl (10.17 ± 3.5), respectively. PBS of AB in ER and SE modes was similar when distilled water was used in the SE mode.Adhesive performance of AB in the ER mode was comparable to or different from the SE mode, depending on the irrigant used to prepare post space in SE approach. AB could behave as a reliable bonding for post cementation. Use of fiber-reinforced composite posts (FRC) has increased in recent years because they provide esthetic and support for the restoration of endodontically treated teeth . FRC posHowever, the establishment of effective bonding within the root canal is still a challenge; consequently, debonding of the post and the endodontic lesion has been described as the predominant failure mode of the restoration . This faEtch-and-rinse (ER) adhesive systems, as the most clinically proven method, have been speculated to benefit from dissolving the smear layer in the root canal . Self-etRecently, universal adhesives (UAs) have been introduced that can be used in ER, SE or selective enamel etching approach, depending on different clinical conditions and clinicians’ preferences . These nHowever, till date, the reported studies have been conducted on coronal dentin and no study has been performed on bonding performance of UAs for post cementation in root canal space using dual-cured resin cements.The use of only one adhesive  for both coronal and root dentin bonding could simplify bonding procedures for post cementation and subsequent coronal build-up. Therefore, the aim of this study was to evaluate bonding effectiveness of All-Bond Universal/resin cement with different adhesive approaches employed to lute FRC posts  in three levels of the root canal. The two-step ER, One-Step Plus  and two-step SE, Clearfil SE Bond  were also assessed as control adhesives. The null hypotheses tested were that 1) push-out bond strength of All-Bond Universal to intraradicular dentin with different adhesive approaches relative to the irrigant used does not differ from the respective control adhesives; 2) the bond strengths are not affected by three root canal levels .Fifty-six sound human maxillary central incisors with similar size and anatomic shape  and straight roots without cracks were selected and stored in 0.5% chloramine T solution at 4°C until used for the purpose of this in vitro study. They were used following informed consent from patients and approval of the research protocol by the Ethical Committee of Shiraz University of Medical Sciences . The roots were separated from the crowns in a uniform length of 15 mm, using a water-cooled diamond saw . The roots were endodontically instrumented at a working length of 1 mm from the apex with K-files  up to #45 with saline solution and sodium hypochlorite and obturated using gutta-percha and AH26 sealer . The filled roots were coronally sealed using light-cured Fuji II LC glass-ionomer . The specimens were stored in water for one week for the complete setting. Afterward, post spaces were prepared to a standardized depth of 10 mm using respective drills from the post manufacturer by the same operator. Cleanliness of the root canal walls and the remaining 4 mm of gutta-percha at the root end for apical seal were confirmed by radiographs.The fiber posts were tried in the canals for a passive fit in the prepared depth. Post surfaces were cleaned with ethanol, air-dried and then coated with the adhesive and light-cured, according to manufacturer’s recommendation.2 using a light-curing unit  according to manufacturer’s instructions. The specimens were stored in distilled water at 37°C for one week.The specimens were randomly divided into seven groups (n = 8) based on irrigation/adhesive procedures as follows. Group 1 : The post space was first irrigated with 5 mL of sodium hypochlorite , followed by 5 mL of distilled water (W). Then, the post space was acid-etched with phosphoric acid for 15 s using an endodontic syringe with endodontic tips, water-rinsed for 30 s, and gently dried with absorbent paper points. One-Step Plus was applied using endodontic brushes. Group 2 : The post space was irrigated with NaOCl as described for group 1and Clearfil SE Bond was applied. Group 3 (CSE/ED): The post space was irrigated with 5 mL of 17% ethylene diamine tetra acetic acid (EDTA) for 60 s, followed by 5 mL of W. After slight drying, CSE was applied. Group 4 (AB-Er/H): After NaOCl irrigation and acid etching as described in group 1, All-Bond Universal (AB) was applied. Group 5 (AB-Se/H): After NaOCl/W irrigation and slight drying, AB was applied. Group 6 (AB-Se/ED): After EDTA/W irrigation, AB was applied. Group 7 (AB-Se/W): AB was applied after W irrigation. Description of the seven groups is shown in 2) and the bond strength was recorded in MPa. The bonded area was calculated through the formula π (R+r) [h2+(R-r) 2]0.5, where R and r represent the coronal and the apical post radii, respectively, and h is the thickness of the slice.The bonded roots were sectioned into seven 1-mm-thick slices by using a slow-speed cutting machine . For each root, two slices from each root region  were obtained . TherefoAll the debonded specimens were assessed under a stereomicroscope  at ×40 and categorized as follows: (1) cohesive failure in dentin; (2) cohesive failure in the cement; (3) adhesive failure between the cement and the dentin; (4) adhesive failure between the cement and the post; and (5) mixed failures consisting of a combination of two or more failure modes.One additional bonded root from each group was prepared for SEM analysis. After sectioning the roots, the sections were treated with 37% phosphoric acid for 15 seconds and 5% NaOCl for 2 minutes. They were then dried in a desiccator for 24 h, sputter-coated with gold and observed under a scanning electron microscope .Data were statistically analyzed using two-way ANOVA and Tukey multiple comparisons (α = 0.05).The results of HSD Tukey tests of all the multiple comparisons among the three root regions were significant (p≤0.001), with a reduction in PBS values from the cervical to the apical region. When various adhesive protocols were compared regardless of the root region, the highest PBS was recorded in the AB-Se/ED group (15.38±3.9). This PBS value was significantly higher than that in the other groups (p≤0.02), but not significantly higher than that in the CSE/ED group . The latter group yielded a significantly higher PBS than that in CSE/H .The lowest PBS was obtained for AB-Se/H (10.17±3.5), which was not significantly different from OS/H , CSE/H (p = 0.76) and AB-Se/W . AB-Se/H had a significantly lower BS compared to that of AB-Er/H . AB-Er/H had a PBS comparable to AB-Se/W and the control ER group, OS/H (p>0.05) . The resThe morphological images of the root dentin-adhesive interface with different irrigant/adhesive protocols under SEM are shown in The present study evaluated the bonding performance of a UA, All-Bond Universal, in differently prepared root canal spaces at three levels with the SE and ER modes. In light of our findings, the null hypotheses were rejected because of significant effects of irrigation/adhesive approaches and the root levels .UAs have pH values ranging between 2 and 3; only AB with a pH of 3.2 is claimed to be compatible with self- and dual-cured resin cements without any separate activator . HoweverSome studies reported better performance of ER adhesive cement than that of SE cement in terms of bonding to root dentin , 19. ThiSodium hypochlorite (NaOCl) is a halogenated compound with an effective antimicrobial capacity and low surface tension . The latThe lower effect of NaOCl compared to EDTA on the performance of the SE adhesives used might be attributed to the lower efficacy of NaOCl for the removal of the smear layer. This was documented in an SEM study by Gu et al . AlthougContrary to phosphoric acid, EDTA as a mild chelating agent enables selective removal of hydroxyapatite and non-collagenous protein while preserving the native collagen structure with interfibrillar mineral. Consequently, the higher stability and lower sensitivity to water content of this substrate along with residual mineral could provide a favorable penetrable bonding substrate for SE adhesives containing functional monomers , 34. TheLong-term storage and thermal fatigue might better predict the clinical behavior of UAs . HoweverConsidering the limitations of this study, bonding effectiveness of AB in ER and SE modes was similar to the respective control adhesives (OS and CSE). Use of irrigants influenced the adhesive performance of the SE mode; it benefitted from EDTA, resulting in better performance of the SE mode than the ER mode. On the contrary, the adverse effect of NaOCl leads to the lower performance of the SE mode compared to the ER mode.S1 Filehttps://doi.org/10.17026/dans-zph-hw9x.(XLSX)Click here for additional data file.


Young (2 months) and old (18 months) male and female mice received 0 (control), 5, 40, 80 or 160 μg/g/d of ISO . IL-1α, IL-4 and vascular cell adhesion molecule-1 (VCAM-1) were quantified in plasma. In vitro, norepinephrine-induced vasoconstriction and acetylcholine-induced relaxation were measured in aortas. No differences in contraction, relaxation, IL-1α, and IL-4 were found between control young males and females. Age decreased contraction in males and relaxation was lower in females and abolished in males. VCAM-1 was higher in young males than in females and increased in old mice. Vasoconstriction in ISO-treated mice results as a bell-shaped curve on contraction in young and old males, with lower values in the latter. In females, ISO-160 increased contraction in young females but decreased it in old females. Vasorelaxation was reduced in ISO-treated young males and females. ISO-80 and 160 reduced vasorelaxation in old females, and intermediate doses relaxed aortas from old males. VCAM-1 was higher in young and old males with ISO-80 and 160; while VCAM-1 was higher only with ISO-160 in old females. Our results demonstrate that repeated β-adrenergic stimulation modifies vascular reactivity depending on gender, age, and dose. Females were less sensitive to alterations in vasoreactivity, and young females required a higher amount of the adrenergic stimuli than old females to show vascular alterations. Changes were independent of IL-1α and IL-4. VCAM-1 only changed in old females stimulated with ISO 160. Our results highlight the relevance of considering and comparing in the same study females and aged organisms to improve the accuracy of applications to clinical studies.Different human-like cardiomyopathies associated to β-adrenergic stimulation are experimentally modeled in animals through variations in dose, route, and duration of administration of different cardiotoxic drugs. However, associated changes in the vasculature and their relation to systemic inflammation, and the influence of cardiovascular diseases risk factors (gender and age) upon them are seldom analyzed. Here we studied the effect of age and gender on the vasoreactivity of aortas from mice subjected to  They are located in the heart, but also in vascular smooth muscle cells, where they mediate vasodilating effects of endogenous catecholamines -induced contraction and acetylcholine (Ach)-induced vasorelaxation in young and old male and female mice, previously injected in vivo with different repeated doses of ISO. This study is important since sensitivity to heart damage caused by the stimulation with different doses of catecholamines that act on the β-adrenergic system is modulated by risk factors such as age and gender. In addition, there is little information on the relation of β-adrenergic stimulation, vasculature function and inflammation which potentiates damage, and therefore, our aim was also to measure the circulating inflammatory mediators IL-1α, IL-4, and VCAM-1 which are known to influence vascular function.Here we studied the differences in ad libitum and under a 12:12 light:dark cycle. Before treatment began, animals were inspected to ensure their good health. For each age and gender, five groups of four mice each were formed. Each group received subcutaneously one of the following doses of ISO for seven days: 5, 40, 80 and 160 μg/g/d. These doses were chosen considering reported minimal and maximal ranges that induce heart damage but not the death of the organisms  and used to determine in vitro contraction to NE and relaxation to Ach.All procedures followed the guidelines established by the Federal Regulation for Experimentation and Animal Care  and the experimental protocol was registered and approved by our institution; protocol INCICH-10-695. Young (2 months old) and old (18 months old) male and female Balb/c mice were used. Animals were kept with food and water −4–10−9 M) on NE- (1 μmol/L) precontracted aortic rings. The half maximal response to Ach (pEC50), expressed as –log10 of the molar concentration of EC50, and the maximum relaxation response (Emax) were calculated. To have an approach on the participation of nitric oxide (NO) on the vasorelaxation, we measured nitrates  and incubated for 30 min at 37°C. At the end of the incubation period, 50 μl of sulfanilamide 1% and 50 μl of N-naphthyl-ethyldiamine 0.1% were added, and the total volume was adjusted to 1 ml. The calibration curve was obtained with a solution of KNO2 ranging 5–0.078 M. The absorbance was measured at 540 nm.Aortas from 4 mice of each group were obtained and carefully cleaned from connective and adipose tissue, taking care not to damage the endothelium. 1 or 2 segments from every aorta were used totaling 6–8 vascular reactivity assays. Tension measurements were made as previously described .Plasma circulating levels of IL-1α , IL-4 , and VCAM-1  were determined by enzyme-linked immunosorbent assay (ELISA) following the manufacturer's instructions using 10 μl of serum from all experimental animal groups . When comparing control values between gender and age, Student's t-test was used with the same program. Statistical analysis of plasma interleukins was made using Student's t-test with the Sigma Stat program (Jandel Scientific). Statistical analysis of body weight was performed by two-way ANOVA, followed by Sidak test, and VW/BW was performed by one-way ANOVA, followed by Dunnet test, using Prisma software. Results are expressed as the mean ± standard error of the mean (SEM). Differences were considered statistically significant when p < 0.05.Statistical analysis of vascular reactivity assays, pEC*10−3g vs. old females: 0.17 ± 0.01 g, respectively).The contraction induced by NE was slightly stronger in aortas from males than from females of 2 months of age  but the difference was not statistically significant. In aged mice, contraction significantly decreased in male aortas, while it remained constant in females  (Table max = 71.6 ± 0.4% vs. 50.0 ± 2.2%); and in male aortas, vasorelaxation was abolished , without changes in old males. Meanwhile, circulating VCAM-1 was not modified by ISO in young females, but it was significantly increased with dose of 160 μg/g/d in old females (2.58-fold vs. control).p < 0.05). VW/BW was higher in vehicle-treated males than in females in both ages  but only reached statistical significance in vehicle-treated old mice. Treatment with ISO did not modify the gender and age-associated BW, but it significantly increased VW/BW in all groups.Changes in ventricular weight (VW) to body weight (BW) ratio (VW/BW) were quantified to corroborate that the doses used induced heart damage. Therefore, the observed changes in vasoreactivity can be related to cardiac damage. Table Overstimulation of the β-adrenergic system with daily doses of ISO causes heart damage inducing inflammation of the tissue and having consequences on the vasculature. In this paper, we studied the effects of repeated β-adrenergic overstimulation with different doses of ISO on vascular reactivity.We found that repeated β-adrenergic stimulation with different doses of ISO modifies vascular reactivity (VR) in an age-, gender-, and dose-dependent pattern being young males the most susceptible to vascular alterations; whereas old mice tended to keep their homeostasis, but with different strategies according to the gender. Even though changes in vascular tone may be associated with systemic inflammation induced by the repeated β-adrenergic stimulation, in our study, we found no changes in the circulating levels of the inflammatory mediators IL-1α and IL-4 and only VCAM-1 seemed to be associated with vascular alterations in old females stimulated with the highest ISO dose. However, we cannot rule out that other biochemical and cellular markers of inflammation and local inflammation markers could be modified.Gender and age modulate the incidence and progression of vascular and heart-related diseases. In the present study, we found no differences in VR between vehicle-treated young males and females. This response is in agreement with previous reports  modifies VR in an age-, gender- and dose-dependent manner being young males more susceptible to damage. Old mice tend to keep their homeostasis, but with different strategies according to the gender. These alterations in VR accompany the heart damage which was evidenced by the increases in VW/BW. A vicious cycle could be established with a tendency to threaten life unless interrupted. Although inflammation and vascular tone are associated with β-adrenergic stimulation, this association might not necessarily involve the participation of the inflammatory cytokines IL-1α and IL-4. Only circulating VCAM-1 levels showed changes in old females stimulated with the highest ISO dose. Therefore, other cellular and humoral participants of the inflammatory response should also be assayed in future studies. Importantly, these results highlight the relevance of considering the gender and age of organisms in studies aiming to determine mechanisms that lead to the incidence of diseases.AC-M and BN-L: designed the study, performed the treatments, obtained the heart and aortic tissues and plasma samples, drafted the interpreted results and wrote and reviewed the manuscript; MR-R: performed the assay of vascular reactivity and drafted the interpreted results; IP-T: performed the assay to determine the inflammatory and nitrite profile; VG-L: was responsible reviewing the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Recent data suggests that several psychopathological conditions are associated with alterations in the variability of behavioral and physiological responses. Pathological worry, defined as the cognitive representation of a potential threat, has been associated with reduced variability of heart beat oscillations  and lapses of attention indexed by reaction times (RTs). Clinical populations with attention deficit show RTs oscillation around 0.05 and 0.01 Hz when performing a sustained attention task. We tested the hypothesis that people who are prone to worry do it in a predictable oscillating pattern revealed through recurrent lapses in attention and concomitant oscillating HRV. Sixty healthy young adults (50% women) were recruited: 30 exceeded the clinical cut-off on the Penn State Worry Questionnaire ; the remaining 30 constituted the Low-Worry (LW) group. After a diagnostic assessment, participants performed two 15-min sustained attention tasks, interspersed by a standardized worry-induction procedure. RTs, HRV and moods were assessed. The analyses of the frequency spectrum showed that the HW group presents a significant higher and constant peak of RTs oscillation around 0.01 Hz (period 100 s) after the induction of worry, in comparison with their baseline and with the LW group that was not responsive to the induction procedure. Physiologically, the induction significantly reduced high-frequency HRV and such reduction was associated with levels of self-reported worry. Results are coherent with the oscillatory nature of the default mode network (DMN) and further confirm an association between cognitive rigidity and autonomic nervous system inflexibility. Excessive worry is a core symptom of generalized anxiety disorder  and has been conceptualized as a chain of thoughts and images, negatively affect-laden and relatively uncontrollable, containing the possibility of one or more negative outcomes and closely related to the fear process  in children with Attention-Deficit/Hyperactivity Disorder (ADHD) reported peculiar RTs oscillations around a peak of 0.05 Hz, indicating lapses in attention occurring about every 20 s . Such a pattern would be consistent with the hypothesis of a recurrent and intrusive DMN activation during goal-oriented activity  and controls . This cut-off has been recommended for optimal sensitivity and specificity in selected samples , menopause, pregnancy or childbirth within the last 12 months. Participants were compensated (€15) for their time. The protocol was approved by the Bioethical Committee of S. Lucia Foundation, Rome, Italy.Participants were recruited by the use of flyers and participation in previous studies. The sample was composed of 60 subjects  years). The cut-off score for pathological worry on the PSWQ . Then, participants performed again the same sustained attention task for 15 min. Before and after performing each task, participants rated their thoughts and moods over the preceding period using visual analog scales. Psychophysiological data were recorded throughout the session.Participants completed a series of socio-demographic and lifestyle  questions and questionnaires to measure levels of: (a) trait rumination , symptom-focused (I think about how hard it is to concentrate), and focused on the possible consequences and causes of one’s mood (I think “I won’t be able to do my job if I don’t snap out of this”).The STAI consists of two 20-item self-report measures to assess state and trait levels of anxiety. Respondents indicate how they feel right now (state version) or how they generally feel (trait version) using four-point Likert scales.The BDI-II requires participants to respond how each of 21 statements relates to the way they have felt for the past 2 weeks. This instrument is intended to assess the existence and severity of symptoms of depression as listed in the American Psychiatric Association .As a sustained attention to response task, we used a modified version of the Continuous Performance Test Conners, , adaptedThe stimuli appeared on a video display unit controlled by an IBM Personal Computer. The software E-Prime version 2.0  the topic selected by each participant during the induction; (2) its temporality (past or future); and (3) temporal distance (how long in the past/how far in the future).At the beginning and at the end of the sustained attention task, participants were asked to rate their current levels of feeling sad, calm and worried on separate visual analog 100-point scales. For each mood, change scores  were computed by subtracting the initial baseline from task values.HR was recorded as beat-to-beat intervals in ms with the Bodyguard 2 (Firstbeat) HR monitor that has been extensively used for HR recording and analysis , obtaining the spectral density of the signal varying over time: scalogram. The scalogram was averaged over the whole task interval to attain the average spectral power per frequency. The maximum powers in each pre-determined range was automatically computed and these values were taken as the dependent variables in the Analysis of Variances (ANOVAs) and Fisher’s LSD  Buzsáki , who arg Buzsáki .P-values ≤ 0.05 were considered as significant. Laboratory data processing and analyses were performed using STATISTICA . Kolmogorov-Smirnov test was used to test the normality of all variables. The distribution for LF-HRV, HF-HRV and LF/HF-HRV was non-normal; therefore these variables were log transformed (ln).Data are expressed as means standard deviation (SD). t-tests.First, pre-existing group and gender differences were analyzed by Second, a series of 2 (Group: High Worriers vs. Low Worriers) × 2 (Induction: Before vs. After) ANOVAs were performed on: (a) HR, ln (LF-HRV), ln (HF-HRV) and ln (LF/HF-HRV); (b) levels of being sad, calm and worried ; (c) mean, SD and coefficient of variability  of RTs; and (d) and percentage of errors. CV has the merit to be a measure of RT variability independent of differences in mean RT  with Group as between-subject factor and Range  and Induction as within-subject factors were carried out on RTs and inter-beat intervals series. CWT spectral power peak served as the dependent variable.post hoc tests were executed in case of significant main effects.Fisher’s LSD Finally, correlational analyses were performed between physiological and attentional responses to the induction and state and trait psychological characteristics of the sample.t = 1.98, p = 0.05). In addition to the PSWQ , pathological worriers had higher levels of: (a) trait  and state anxiety ; (b) depression ; and (c) trait rumination .Table ps > 0.15), therefore gender was not included as a covariate in the subsequent analyses. In light of pre-existing differences between the two groups, BMI was included as a covariate in all the subsequent analyses.No gender differences emerged for any of the examined physiological variables  days. In both groups, most participants chose to worry about work-related issues (n = 18 in the HW and n = 20 in the LW groups), followed by romantic, health and family issues.With regard to the Induction, F = 4.61, p < 0.05; Post hoc comparisons showed that HF significantly decreased from pre- to post-induction in the HW group only (p = 0.002). The ANOVAs did not yield significant main effects of Group or Induction. BMI did not play a significant role as a covariate in the model. No significant main effects or interactions emerged for HR, LF-HRV or LF/HF-HRV.Table F = 3.91, p < 0.05; F = 3.99, p < 0.05; A main effect of Group emerged for levels of Worry  = 6, p < 0.05; post hoc comparisons revealed that mean RTs significantly decreased in the LW group from pre- to post-induction (p < 0.01); such an effect was not present in the HW group. Interestingly, a significant pre- to post-induction increase in CV was found in the HW group (p < 0.05).A significant main effect of Induction emerged from the ANOVA on average RTs  = 43.4, p < 0.001; F = 2.7, p < 0.05; Post hoc analyses on the main factor Range revealed the following differences: Slow 6 = 5 > 4 = 3. Post hoc comparisons on the Range × Group interaction showed a significant higher spectral power mean value in the HW group compared to the LW group in Slow 6 (0.0052 Hz–0.010 Hz).The group averaged CWT was performed on inter-beat intervals time series acquired during task performance and returned the maximum peak in each of the four frequency ranges. The mixed three-way ANOVA reported a significant main factor of Range  compared to those of the LW group; (b) after the induction compared to pre-induction. As shown in Figure F = 49.7, p < 0.001; F = 4, p < 0.05; F = 4.3, p < 0.01; post hoc analysis revealed that whereas HW participant significantly increased their power peaks in Slow 6 after the worry induction (p < 0.05), the LW group showed an opposite and marginally significant trend, decreasing power peak values in Slow 6 after the induction (p = 0.07). The significant Group × Induction interaction in Slow 4 was due to a significant power decrease in the LW group after the induction (p < 0.05).The mixed three-way ANOVA (Group × Range × Induction) on peak power as dependent variable yielded a main effect of Range  showed that HRV reactivity to the induction was negatively associated with changes in state worry (r = −0.70) from pre- to post-induction (change scores). RT power in Slow 6 before induction was positively correlated with HR (r = 0.37) and inversely correlated with LF-HRV (r = −0.31) and HF-HRV (r = −0.29). The RT power in Slow 6 after the induction was positively correlated with state anxiety (r = 0.27) and increases in levels of sadness from pre- to post-induction (r = 0.26). HR power in Slow 6 in the HW group after—but not before—the induction was positively correlated with BDI score (r = 0.45).Correlation analyses  showed that both behavioral and cardiac-autonomic indices oscillate in a very low frequency range  in pathological worriers with a peak value just before 0.01 Hz. In particular, data on RT series in the HW but not in the LW group showed a clear increase of power in the 0.005–0.01 Hz range after the worry induction procedure, suggesting an increase of behavioral variability around 0.01 Hz and therefore possibly the increase of negative thought intrusions at a regular oscillation around 100 s  but, in this case, this was already present in worriers at the baseline evaluation and hence did not show any further increase after the worry induction. Taken together, present data may suggest that inter-beat intervals oscillations reflect a “trait” characteristic of high worriers, whereas RT oscillations might be a more sensitive index of “state” pathological worry.The oscillation frequency of RTs and inter-beat intervals in the 0.005–0.01 Hz range found in this study is consistent with previous observation of DMN frequency activation , cognitive (increased propensity to lapses in attention) and behavioral levels (increased RTs variability). At a central nervous system level, this association is presumably mediated by the midline cortical structures belonging to the DMN.SG, CO, FM conceived and designed the experiments. MD, FA, BP performed the experiments. SG, CO, AN analyzed the data. AN, MD, FA, BP contributed materials/analysis tool. SG, CO, AN, FM, MD, FA, BP contributed to the writing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


P <0.05). At a median follow-up of 96 months, median PFS for T-CHOP group was still not reached yet, and in CHOP group it was 22.9 months (95% CI [0-50.4]). (P=0.163). Median overall survival (OS) for T-CHOP group was also not reached, and the estimated median OS for CHOP group was 83.5 months, the difference of OS between the two groups is not significant (p=0.263). But, in patients with Bcl-2 positive and Bcl-6 negative, the median PFS in T-CHOP group was longer than that in CHOP group (111.0 vs 8.5 months (P=0.017). In addition, thalidomide did not significantly increase the grade 3/4 toxicity of CHOP. We concluded that the addition of thalidomide to the CHOP regimen significantly improved the CRR and showed a trend of improving clinical outcome in patients with DLBCL, especially for patients with Bcl-2 positive and Bcl-6 negative B-cell phenotype, without increased toxicity.Cyclophosphamide, doxorubicin, vincristine, and prednisolone plus rituximab (R-CHOP) is the standard treatment for patients with diffuse large B cell lymphoma (DLBCL). However, rituximab cannot be popularly applied in a considerable number of patients with DLBCL because of economic reasons. To develop a new regimen to improve the outcome of these patients is extremely important. In our study, sixty five patients with DLBCL were randomly assigned to thalidomide plus CHOP group (n=32) or to CHOP alone group (n=33). Objective response rates (ORR) and complete remission rates (CRR) were 96.7% and 80.6% in T-CHOP group versus 78.9 % and 57.8 % in CHOP group, respectively ( DLBCL is the most common type of malignant lymphoma, accounting for about 31% of all NHL –4. The fRituximab, a chimeric monoclonal antibody targeted CD20 antigen, can be used for the treatment of CD20 positive B cell lymphoma. Compared with CHOP scheme, rituximab plus CHOP (R-CHOP) can significantly improve complete remission rate, and prolong event free survival (EFS) and OS , 7. And Angiogenesis play an important role in tumor invasion and metastasis. Anti-angiogenesis therapy has become an important part of the comprehensive treatment for malignant tumors. It is reported that 60% of the DLBCL specimens showed higher local vascular endothelial growth factor (VEGF) expression, higher VEGF receptor (VEGFR) expression and correspondingly higher micro-vessel density , which pDLBCL is a heterogeneous disease with different morphological and molecular characteristics . It can Thalidomide is a kind of glutamate derivatives. In the late of last century, people found that thalidomide can inhibit angiogenesis by blocking bFGF and VEGF, and it can also modulate the immune system by co-stimulating T cell proliferation –14. In rClinicalTrials.gov.)In this open-label, randomized, controlled study, the efficacy and tolerability were compared between thalidomide combined with CHOP (T-CHOP) and CHOP alone in chemo-naïve DLBCL patients.  for further treatment; 65 patients were included in the final analysis . One patient in T-CHOP group and two patients in CHOP group had cyclophosphamide and epirubicine dose reduction to 75%. In T-CHOP group, one patient stopped to receive thalidomide after the first cycle of treatment because of the onset of angina, and another three patients continued to receive thalidomide at a dose of 200mg because they had incontinent urinate when the dosage increased to 400mg per day. There were no significant differences between the two groups in any of the baseline clinical characteristics Table . CentralThe baseline characteristics were also balanced between CHOP and T-CHOP group in different Bcl-2 and Bcl-6 status patients see .In this study, CR rate in T-CHOP group was higher than that in CHOP group, . Overall response rate  in CHOP group was 78.8% 26/33) and in T-CHOP group was 96.9% (31/32)  , and for CHOP group it was 22.9 months (95% CI [0-50.4]). Median OS for T-CHOP group was not reached, and the estimated median OS for CHOP group was 83.5 months. The survival curves of PFS and OS between these two groups separated, but the differences were not significant, with P values of 0.237 and 0.396, respectively Figure . Figure The sample size of Bcl-2+/Bcl-6- patients was 11, and Life Tables method was applied to compare the PFS and OS between T-CHOP and CHOP group. The mPFS for this group of patients treated with T-CHOP was 111.0 months, and for those treated with CHOP was 8.5 months. T-CHOP showed significant superiority over CHOP in PFS in Bcl-2+/Bcl-6- patients (P=0.017) Figure . In thisTable One patient diagnosed as DLBCL in Dec 2006. He received T-CHOP for 6 cycles and got CR after the first two cycles. This patient relapsed in Apr 2012, he underwent autologous stem cell transplantation and got 2nd CR. In Feb 2016, he had enlargement of the lymphonode. He received biopsy and was diagnosed as mantle cell lymphoma. It's hard to judge whether the MCL is transformed from DLBCL or the secondary malignancy.In this randomized study, there were three main findings. First, we found that the CRR and ORR in T-CHOP group was significantly higher than that in CHOP group for previously untreated patients with DLBCL Table , which mBcl-2 protein, an anti-apoptotic molecule, is expressed in 22–80% of DLBCLs and Bcl-2 positivity has been reported to be associated with an unfavorable prognosis. Bcl-6 protein is expressed in about 47–84% of DLBCLs. Bcl-6 rearrangement and Bcl-6 protein expression were reported to be associated with favorable clinical outcome –28. In tLenalidomide, an expensive analogue of thalidomide, showed significant activity in relapsed DLBCL. In a phase II study, lenalidomide combined with R-CHOP could overcome negative prognostic impact of non–germinal center B-cell phenotype in newly diagnosed DLBCL , 30.2, about 180,000 RMB Yuan is needed for 6 cycles of Rituximab, about 6,000 Yuan for 6 cycles of CHOP, and about 3,500 Yuan for 6 cycles of thalidomide. In some under-developed areas in middle and west China, many people with CD20 positive lymphomas cannot afford Rituximab. T-CHOP is a regimen that worth further investigation for this patient population.Many cost-effectiveness analyses reported that adding rituximab to CHOP in DLBCL patients is cost-effective –33. In 2Thus, this study has identified, for the first time, a safe and effective regimen for treating patients with DLBCL who cannot afford rituximab. In this study, no statistically significant difference in OS was found between the T-CHOP group and the CHOP group, which might be mainly attributable to the relatively small sample size of this study.In conclusion, our study showed that T-CHOP was a highly effective and low-toxicity regimen that might be considered as a new regimen for the treatment of DLBCL patients who cannot afford rituximab. It is showed that the Bcl-2 positive/Bcl-6 negative DLBCL patients gained survival benefit from adding thalidomide to the CHOP regimen.As a phase II clinical trial designed in 2005, there were some limitations of our study. First, the sample size is relatively small to detect the difference in survival. Second, we didn't introduce the GCB/non-GCB subtype detection in this study, and IHC detection of Bcl-2 and Bcl-6 was not done in every patient. Third, the dose-intensity of CHOP regimen in our study is lower than the standard regimen. Since there was no report about thalidomide combined with CHOP for newly diagnosed DLBCL patients published so far, our findings need to be further validated in the future.Patients age between 18 and 75 years old and had untreated diffuse large B cell lymphoma that had been diagnosed according to the World Health Organization classification. Additional enrollment criteria were as follows: an Eastern Cooperative Oncology Group performance status of 0-2; a more than 3 months life expectancy; and acceptable hematologic, hepatic, renal and cardiac function. Patients with a history of deep venous embolism (DVE) or pulmonary embolism (PE) were excluded. Pregnant and lactating women were also excluded.This trial was approved by the institutional review board, the Fudan University Shanghai Cancer Center Ethics Committee for Clinical Investigation on Dec 29th, 2005. All patients were told that they should take R-CHOP as the induction chemotherapy regimen if they can afford rituximab. Patients who cannot afford rituximab can choose to participate in this clinical trial. This trial is conducted in accordance with the Declaration of Helsinki and Good Clinical Practice. All patients provided written informed consent according to institutional guidelines.Eligible patients were randomly assigned according to the sequence of the time they signed the informed consent form. The randomization table was generated by the Stata software.2 d1, epirubicin 60mg/m2 d1, vincristine 1.4 mg/m2 [capped at 2.0 mg] d1, and prednisone 60mg/m2 per day on d1-5). Patients in the T-CHOP group also received thalidomide. Thalidomide 200 mg per day was administered on days 6-21 in the first cycle, if the patient can tolerate it well the dosage will be added to 400 mg per day on days 6-21 since the second cycle or he/she will continue to receive 200mg per day. Patients who had grade 4 neutropenia or febrile neutropenia after any cycle of chemotherapy were given G-CSF. The dose of cyclophosphamide and epirubicine will decrease 25% if the patient experience grade 4 hematological toxicity. CT imagings of lymphoma involved area were repeated every two cycles. No prophylactic anticoagulation medications were given to patients who received thalidomide. The treatment continued for a maximum of 8 cycles or until disease progression.Patients in the control group received CHOP regimen (cyclophosphamide 600mg/mTumor response and progression were determined according to the International Workshop Criteria . The priReported data showed that the CR rate in Chinese DLBCL patients treated with CHOP was 37.5-52.8% , 21. In


Background: Remifentanil-induced hyperalgesia (r-IH) involves an imbalance in the inhibitory and excitatory systems. As the transcranial Direct Current Stimulation (tDCS) modulates the thalamocortical synapses in a top-down manner, we hypothesized that the active (a)-t-DCS would be more effective than sham(s)-tDCS to prevent r-IH. We used an experimental paradigm to induce temporal summation of pain utilizing a repetitive cold test (rCOLDT) assessed by the Numerical Pain Score (NPS 0-10) and we evaluated the function of the descending pain modulatory system (DPMS) by the change on the NPS (0–10) during the conditioned pain modulation (CPM)-task (primary outcomes). We tested whether a-tDCS would be more effective than s-tDCS to improve pain perception assessed by the heat pain threshold (HPT) and the reaction time during the ice-water pain test (IPT) (secondary outcomes).Methods: This double-blinded, factorial randomized trial included 48 healthy males, ages ranging 19–40 years. They were randomized into four equal groups: a-tDCS/saline, s-tDCS/saline, a-tDCS/remifentanil and s-tDCS/remifentanil. tDCS was applied over the primary motor cortex, during 20 min at 2 mA, which was introduced 10 min after starting remifentanil infusion at 0.06 μg⋅kg-1⋅min-1 or saline.Results: An ANCOVA mixed model revealed that during the rCOLDT, there was a significant main effect on the NPS scores . The s-tDCS/remifentanil group presented larger pain scores during rCOLDT, [mean (SD) 5.49 (1.04)] and a-tDCS/remifentanil group had relative lower pain scores [4.15 (1.62)]; showing its blocking effect on r-IH. a-tDCS/saline and s-tDCS/saline groups showed lowest pain scores during rCOLDT, [3.11 (1.2)] and [3.15 (1.62)], respectively. The effect of sedation induced by remifentanil during the rCOLDT was not significant . Remifentanil groups showed positive scores in the NPS (0–10) during the CPM-task, that is, it produced a disengagement of the DPMS. Also, s-tDCS/Remifentanil compared to a-tDCS showed lower HPT and larger reaction-time during the IPT.Conclusion: These findings suggest that effects of a-tDCS prevent the summation response induced by r-IH during rCOLDT and the a-tDCS blocked the disengagement of DPMS. Thereby, tDCS could be considered as a new approach to contra-regulate paradoxical mechanisms involved in the r-IH. Clinical trials identification: NCT02432677. URL:https://clinicaltrials.gov/. Opioids are the most effective analgesics to treat moderate to severe acute and chronic pain. However, growing evidence shows that opioids can elicit unexpected changes in pain sensitivity. This hyperalgesia induced by opioids (OIH) may extend beyond the postoperative period and can lead to the development of chronic pain persisting for months . ConsideN-methyl-D-aspartate (NMDA) receptors (NR1A/2A and NR1A/2B), and hence, it induces a dysfunction of the descending pain modulatory system (DPMS), which is rich in both inhibitory mu-opioid and excitatory NMDA receptors  effects in rats , 1993 aneceptors . In facteceptors . Also, keceptors . Finallyeceptors . Despitein vitro, tDCS can affect long-term-potentiation (LTP) dependent on N-methyl D-aspartate  is a promising approach to contra-regulate OIH, because it modulates the thalamocortical synapses in a top-down manner within pain pathways . The tDCspartate . Also, ispartate , GABAergspartate , glutamispartate , cholinespartate , serotonspartate , and dopspartate .In this sense, to investigate the therapeutic effect of tDCS in OIH, we used accurate tests to evoke OIH, as well appropriate approaches to detect and measure its presence. According to previous studies, OIH is dependent on the nature of the pain model used, and the cold pain test has demonstrated to be the most sensitive of the methods tested in detecting opioid-related hyperalgesia . Thus, dTaking this into account, and considering how tDCS modulates the thalamocortical synapses in a top-down manner, we hypothesized that the active (a)-t-DCS would be more effective than a sham(s)-tDCS to prevent r-IH. We used an experimental paradigm to induce temporal summation of pain utilizing a repetitive cold test (rCOLDT) assessed by the Numerical Pain Score (NPS 0-10) and we evaluated the function of the DPMS by the change on the NPS (0–10) during the conditioned pain modulation (CPM)-task (primary outcomes). We tested whether a-tDCS would be more effective than s-tDCS to improve pain perception assessed by the heat pain threshold (HPT) and the reaction time during the ice-water pain test (IPT) (secondary outcomes).Figure 1.This is a randomized, double-blinded, parallel clinical trial, conducted by the CONSORT guidelines. This study was registered at the ClinicalTrials.gov on April 6, 2015 . The Research Ethics Committee at the Hospital de Clinicas de Porto Alegre approved this protocol. All volunteers provided their written informed consent before participating in the study. The Experimental design, assessments, and interventions are presented in The volunteers were recruited from the general population by advertisement postings in public places in the Porto Alegre area. Participants were considered eligible to participate if they were male, right-handed, and between 19 and 40 years of age. They were screened for eligibility by phone to answer a structured questionnaire that assessed the following variables: sleep disorders, chronic diseases, substance abuse, or alcohol use in the past 6 months, use of psychotropic drugs, history of brain surgery, tumor, stroke or implantation of intracranial metal. Individuals responding affirmatively to any of these questions, those with contraindications for tDCS  or if th-1⋅min-1  placebo solutions were prepared in coded (indistinguishable) infusion syringes attached to a continuous syringe pump with a dose of 0.06 μg⋅kg-1⋅min-1 . Except 2 sponge (moistened with NaCl). The current flow time and the intensity were set at 20 min and 2 mA, respectively. In sham-tDCS, the current flow was applied only for 30 s and turned off, to prevent the subjects from recognizing it from active tDCS. The timeline of study is presented in Figure 2.The tDCS anode, active or sham, was positioned over the primary motor cortex (M1), and the cathode was placed on the right supraorbital region. tDCS was introduced 10 min after the beginning of infusion  to ensure adequate concentration at the effector site according to pharmacokinetic characteristics of the drug. Each tDCS session lasted for 20 min. The rubber electrodes were inserted into a 35-cmThe primary outcome was the DPMS function as assessed by the NPS (0–10) during the QST applied simultaneously with a painful heterotopic stimulus, the rCOLDT and the change on the NPS (0–10) during the CPM-task. The secondary outcomes were the ascendant pain pathway and cortical involvement which was assessed by the HPT and the reaction time evaluated by the area under the curve using a Visual Analogue Scale (AUCVAS).To measure the CPM-task, we assessed the pain intensity during two tonic HPT test stimuli separated by a CPM-task. To induce a prolonged pain sensation to trigger CPM we used the HPT. The CPM-task consisted of immersion of the non-dominant hand in cold water (zero to 1°C) for 60 s. The QST procedure was introduced after 30 s of cold-water immersion over the right forearm (dominant forearm) using a temperature individually predetermined to produce a pain score of 6/10 in the NPS during the pretesting sessions. To determine the CPM, we used the difference between the pain score on the NPS (0–10) QST during cold-water immersion (QST+CPM) at the temperature of the point at which subjects felt 6/10 pain on the NPS scale [during the initial period (T0)].To examine the temporal summation of the second pain, we used a trial of three identical nociceptive stimuli to elicit a pain score of 6/10 in the NPS (test stimulus). A 5 min interval separated each trial. To produce a standard painful stimulus during each trial, they had to immerse their non-dominant hand in cold water (zero to 1°C) for 60-s. After 30-s of immersion, the test stimulus (QST) was applied, and they rated their pain on the NPS (0–10). The increase of 15% on the NPS (0–10) from the baseline was considered to present hyperalgesia. An accepted criterion to define a minimally important change on the NPS (0–10) is a modification of 10–20% . Thus, wThe method of limits with a computer Peltier-based device thermode (30 mm × 30 mm) was used to assess the HPT . The the∗ 120 s or 600 cm ∗ second. Higher values of the area under the effect curve (AUEC) for reaction time (AUECVAS) indicates longer reaction time response.The non-dominant hand was immersed in ice water (0 ± 1°C) for a maximum of 120 s. The subjects were asked to continuously score their maximal pain intensity perceived on a 0–10 cm electronic visual analog scale (VAS), where 0 represents ‘no pain’ and 10 represents the ‘worst pain imaginable.’ Subjects were recorded as 120 s if they did not withdraw their hand for the maximum time. For subsequent analysis of peak pain intensity, the area under the time curve was considered as well as the mean pain intensity. If a subject indicated 5 cm pain  for 120 s, the AUEC value was 5 cm n = 12) in 1:1:1:1 ratio to test 1 point [Standard deviation (SD = 2)] mean a difference between groups for the NPS (0–10). The NPS (0–10) was used to assess both primary outcomes (rCOLDT and CPM-task).The number of subjects in each study group was determined by the parameters of a previous survey . To achiThe sequence of randomization was generated by a computer with a fixed block size of 6. Forty-eight subjects were randomly allocated to receive treatment . Before the recruitment phase, brown envelopes containing the protocol materials were prepared. Each envelope was sealed and numbered sequentially and contained an allocated treatment. Only the individuals responsible for administering the interventions were not blinded. All other participants were blinded to the allocated interventions.Pain catastrophizing was assessed using the validated Brazilian-Pain Catastrophizing Scale . DepressThe differences between groups were examined with the analysis of variance (ANOVA) for parametric variables or the Kruskal–Wallis tests for non-parametric distributions. Categorical variables were examined using chi-square or Fisher’s exact and Kruskal–Wallis tests. The values are presented as the mean (standard deviation) or frequency. Continuous variables were tested for normality using the Shapiro–Wilks test.A mixed ANCOVA model in which the independent variable was the time, the intervention , interaction time vs. the treatment group, and subject identification was used to analyze the score change on the NPS (0–10) during the rCOLDT test and the change on the NPS (0–10) during the CPM-task.A multivariate covariance analysis (MANCOVA) model was used to explore effects between the intervention groups in the multiple outcomes . The effect of all intervention groups on the outcomes were adjusted by sleepiness. All analyses were corrected for multiple comparisons using the Bonferroni test. All analyses were performed with two-tailed tests. We accepted a type I error of 5%. Statistical analyses were performed assuming intention-to-treat. The analyses were performed with the SPSS version 22.0 .Table 1 . The incidence of tDCS associated side effects was reported by <15% of subjects and it was similar between groups. Itching in several body regions was reported in two subjects (16.6%) and four subjects (33.3%) in the a-tDCS/Remifentanil and s-tDCS/Remifentanil, respectively. Nausea was reported in four subjects (33.3%) and in five subjects (41.6%) in the a-tDCS/remifentanil and s-tDCS/saline, respectively. Vomiting was reported in one subject (8.3%) in the s-tDCS/remifentanil group. However, the frequency of these adverse effects was not statistically different between groups. The scores on the VAS (0–100) showed that a-tDCS/remifentanil and s-tDCS/remifentanil-induced higher sleepiness than the other groups  (Table 1).The characteristics were similar across the four groups as shown in Table 2. The incidence of hyperalgesia was 22% in the group that received the a-tDCS/remifentanil compared to 8.3% in the group that received s-tDCS/placebo; the relative risk (RR) for the a-tDCS/remifentanil was 2.75 . The incidence of hyperalgesia in the group that received the s-tDCS/remifentanil was 30.3% compared to s-tDCS/placebo, the RR for the s-tDCS/remifentanil was 3.87 . The incidence of hyperalgesia in the group that received the a-tDCS/saline was 11% compared to s-tDCS/saline, the RR for the s-tDCS/remifentanil was 1.38 . We observed that the RR to show r-IH increased approximately fourfold when the s-tDCS/remifentanil was used. Although the a-tDCS combined with remifentanil reduced the incidence of r-IH in 8%, the RR to induce hyperalgesia was yet significantly greater than those not receiving remifentanil.Mean ± SD and median interquartile  of pain score on the NPS (0–10) during RCOLDT according to interventions at pre-intervention (T0), and post-intervention (T1 to T3) are presented in Figure 3. An ANCOVA mixed model revealed a significant main effect of interventions on the NPS (0–10) during the rCOLDT . The analysis showed a significant interaction between the group of interventions and time . The time effect was not observed . The effect of the sedation reported on the NPS (0–10) during the rCOLDT was not significant .A mixed ANCOVA model in which the independent variable was the time, the intervention , interaction time vs. the treatment group, and subject identification was used to analyze the score change on the NPS (0–10) during the rCOLDT test and the change on the NPS (0–10) during the CPM-task. The mean in the NPS (0–10) during the rCOLDT is presented in P < 0.001, for all comparisons). The mean (SD) on the NPS (0–10) during the rCOLDT pretreatment vs. the cumulative pain scores according to marginal means (T1–T3) in the a-tDCS/remifentanil was 4.62 (1.56) vs. 4.15 (1.55) and for the s-tDCS/remifentanil group was 4.45 (2.10) vs. 5.49 (1.04), respectively. Whereas, for the a-tDCS/saline, these values were 4.7 (1.72) vs. 3.11 (1.2) and for the s-tDCS/saline group these values were 4.62 (1.62) vs. 3.15 (1.62), respectively. The difference in the mean [CI 95%] within the a-tDCS/remifentanil group was 0.47 , a small effect size (Cohen’s f = 20.3). The difference in the mean within the s-tDCS/remifentanil group was -1.04 , a medium effect size (Cohen’s f2 = 0.49). Whereas in the a-tDCS/Saline, it was 1.59 , a large effect size (Cohen’s f2 = 0.93) and in the s-tDCS/saline it was 1.47 , a medium effect size (Cohen’s f2 = 0.72). It is possible to see that the effect size in the groups receiving remifentanil was determined by the increase in pain scores in the cumulative pain scores during the treatment, whereas the effect size observed when they are receiving a-tDCS or s-tDCS with saline was determined by a decrease in the pain scores during the treatment.The change within the group was significant in all treatment groups  [F =  = P < 0.001)]. Also, there is a significant effect of time  and a significant interaction between intervention and time F = . The sleepiness level influenced the NPS during the CPM-task . The change on the NPS (0–10) during the CPM-task in groups receiving remifentanil showed positive values on the NPS scores, that is, it produced a disengagement of the DPMS.The mean in the NPS (0–10) during the CPM-task is presented in Table 2). A MANCOVA analysis revealed a significant relationship between the intervention groups and the HPT as well as in the AUECVAS . The power of this analysis was 98%.Patients receiving (a-tDCS/remifentanil), (s-tDCS/remifentanil), and  showed a greater HPT compared to . Their effect size assessed by the SMD within the (a-tDCS/remifentanil) group was 0.85 while the (s-tDCS/remifentanil) was 0.37. That is, the s-tDCS/remifentanil showed lower HPT compared to a-tDCS combined with the remifentanil or saline (f2 = 0.31) for the pain measured by AUECVAS . While the Sleepiness level had a small effect size for the HPT (Cohen’s f2 = 0.09) . The multivariate model is presented in Table 3.Sleepiness was inversely correlated with the response to the IPT assessed by the AUECVAS, in the sense that more sleepiness was associated with greater reaction time. The sleepiness had a medium effect size (Cohen’s The main results of this study can be summarized by three major findings: (1) we showed that r-IH involves the dysfunction of the inhibitory pathways or up-regulation of the pain-facilitating pathways. This effect was demonstrated by the disengagement of the DPMS measured by the change in the NPS (0–10) during the CPM-task and by the summation effect on pain scores during the rCOLDT; (2) a-tDCS blocks r-IH. (3) a-tDCS/saline  has no effect on pain modulation during the rCOLDT in healthy subjects (likely due to a floor effect). Finally, according to the AUECVAS measurements, adjusted by the sleepiness, the remifentanil group showed a longer reaction time during the IPT compared to the other groups while the a-tDCS improved the HPT.a-tDCS induced a large size effect to prevent r-IH, an effect with a statistical significance and further clinical relevance, especially because opioids are a powerful tool in the treatment of pain. Also, because OIH has been described with acute and chronic exposure, even using different types of opioids at high and low doses . TherebyThe effect of tDCS mitigates part of the dysfunction in pain pathways induced by remifentanil as displayed by its effect on the NPS during the rCOLDT. This result fits nicely with the putative effects of tDCS in chronic neuropathic pain . In thisAlso, the r-IH observed in our study are aligned with the previous study, which measured the DNIC, in which exogenous opioids suppressed the endogenous opioid system and led to an increased sensitivity to pain . HoweverThe central role of the glutamatergic system to induce OIH may be due to an increase of glutamate available to NMDA receptors by a decreased reuptake of glutamate . HoweverIt is important to address several issues concerning the design of our study: First, we include males only to exclude the influence of the cyclical fluctuation of gonadal steroids during the menstrual cycle on pain threshold in females . Second,These findings suggest that effects of a-tDCS prevent the summation response induced by r-IH during rCOLDT, and also that a-tDCS blocked the disengagement of DPMS. Thereby, they revealed that tDCS could be a new approach at contra-regulating paradoxical mechanisms involved in r-IH. In fact, these results have physiological implications to support an understanding of the mechanisms involved in the pathophysiology of r-IH as well as supporting the development of new approaches to treat OIH.GB and FF conceived the study, participated in its design and coordination, performed the statistical analysis, and helped for drafting the manuscript. SP, FL, and AS participated in the sequence alignment. LS and AP conceived the study, participated in its design and coordination, and helped for drafting the manuscript. IT participated in the sequence alignment and drafted the manuscript. WC is responsible for maintaining the study records, conceived the study, participated in its design and coordination, helped for drafting the manuscript, and performed the statistical analysis.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.